Acute kidney injury in subarachnoid hemorrhage: Exploring its clinical significance and prognostic implications.

OBJECTIVES: Subarachnoid hemorrhage (SAH) from spontaneous aneurysm rupture is a debilitating condition with high morbidity and mortality. Patients with SAH remain understudied, particularly concerning the evaluation of incidence and consequences of subsequent acute kidney injury (AKI). In this study, we aim to explore the risk factors and outcomes of AKI in SAH patients. MATERIALS AND METHODS: International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes were used to query the National Inpatient Sample (NIS) for patients with a diagnosis of SAH between 2010-2019. Subgroup analysis was stratified by AKI diagnosis during the same hospitalization. AKI and non-AKI groups were assessed for baseline clinical characteristics, interventions, complications, and outcomes. Descriptive statistics, multivariate regressions, and propensity score-matching were performed using IBM SPSS 28. RESULTS: Of 76,553 patients diagnosed with nontraumatic SAH between 2010-2019, 10,634 (13.89 %) had a comorbid diagnosis of AKI. SAH patients with AKI were older (p < 0.01) and more often obese (p < 0.01) compared to the non-AKI group. A multivariate regression found the diagnosis of AKI to be independently correlated with poor functional outcome (p < 0.001), above average length of stay (p < 0.001), and in-hospital mortality (p < 0.001) when controlling for age, SAH severity, and other comorbidities. CONCLUSIONS: This study showed significant association between AKI and adverse outcomes in SAH patients, and a correlation between AKI and heightened complication rates, poor functional outcome, extended hospital stays, and elevated mortality rates. Early detection of AKI in SAH patients is vital to improve their chances of recovery.

Decision-Making for Patients With Cerebral Arteriovenous Malformations.

Cerebral arteriovenous malformations (AVMs) are a complex and heterogeneous pathology which require an understanding of the natural history of these lesions, as well as the potential treatment options in order to manage them safely. While treatment is the agreed upon strategy for most ruptured AVMs, the management of unruptured AVMs continues to be debated. More recently, this debate has been fueled by the A Randomized Trial of Unruptured Arteriovenous Malformations (ARUBA) trial which attempts to define the natural history and treatment risk of AVMs. However, the trial has significant shortcomings which limit its broad applicability. In addition, the breadth, efficacy, and safety of potential treatment options continue to improve. This review focuses on defining the natural history of cerebral AVMs, an overview of the ARUBA trial, and the most current treatment paradigm for cerebral AVMs.

Management of Small Unruptured Intracranial Aneurysms: To Treat or Not to Treat?

Unruptured intracranial aneurysms measuring <7 mm in diameter have become increasingly prevalent due to advances in diagnostic imaging. The most feared complication is aneurysm rupture leading to a subarachnoid hemorrhage. Based on the current literature, the 3 main treatments for an unruptured intracranial aneurysm are conservative management with follow-up imaging, endovascular coiling, or surgical clipping. However, there remains no consensus on the best treatment approach. The natural history of the aneurysm and risk factors for aneurysm rupture must be considered to individualize treatment. Models including population, hypertension, age, size of aneurysm, earlier subarachnoid hemorrhage from a prior aneurysm, site of aneurysm score, Unruptured Intracranial Aneurysm Treatment Score, and advanced neuroimaging can assist physicians in assessing the risk of aneurysm rupture. Macrophages and other inflammatory modulators have been elucidated as playing a role in intracranial aneurysm progression and eventual rupture. Further studies need to be conducted to explore the effects of therapeutic drugs targeting inflammatory modulators.

Time to Wake-Up: Extending the Window for Management of Unknown-Onset Strokes.

The term "Wake-Up Stroke" is applied to a patient who displays no symptoms before sleep, but wakes with neurologic deficits suggestive of stroke. The current guidelines for acute ischemic stroke limit intravenous tissue plasminogen activator use to stroke patients in whom symptom onset or last known well is less than 4.5 hours. Approximately one-third of acute ischemic stroke patients present with unknown time of symptom onset and are often not eligible for intravenous reperfusion therapy in clinical practice. This review provides an overview of several earlier trials that used advanced neuroimaging to determine eligibility for reperfusion therapy in patients with unknown stroke onset. The reassuring results of these earlier trials that led to recent thrombolysis trials specifically targeted at "wake-up stroke" patients are discussed in this review. Ongoing studies aim to expand our knowledge regarding the safety and efficacy of thrombolysis in these patients.

Climate co-benefits of alternate strategies for tourist transportation: The case of Murree Hills in Pakistan.

This study explores the climate impacts of on-road tourist transportation with alternate mitigation strategies. To this end, greenhouse gas (GHG) emissions for 2016 and emissions under four "what-if" scenarios were estimated for a popular tourist site in Pakistan, i.e., Murree Hills, using the international vehicle emissions model. Alternate scenarios included occupancy optimization, bus transit system, and Euro II and Euro IV implementation. The emissions were further decomposed using the log mean Divisia index method to study the drivers of global warming potential (GWP) mitigation. As per the results, the total 20-year GWP for 2016 was equal to 51,262 tons CO2 equivalent, and maximum reduction was achieved under the bus transit system scenario having a 20-year GWP of 25,736 tons CO2 equivalent, i.e., 49.8% reduction. Relative to the base year, GWP reductions were also quite significant for Euro IV (46.8%), Euro II (45.8%), and occupancy optimization (32.3%) scenarios. For the base year, CO2 held a share of 87.3% in total emissions; however, its share in the 20-year GWP was 39.7% indicating its reduced impact on total GWP as compared to N2O, CO, NOx, VOC, and CH4. Based on the decomposition results for alternate scenarios, GWP mitigation was mainly driven by CO, CH4, NOx, VOCs, and partially by CO2, while N2O negatively affected GWP mitigation. These results provide several policy-level instruments for developing countries to design a transition to an eco-friendly tourist transport management system. The policy implications from this study can be used to promote an eco-tourism industry.

Short term clinical outcomes of Everolimus-eluting stents in patients with stable angina pectoris.

BACKGROUND & OBJECTIVE: Everolimus-eluting stents, compared with bare metal stents, reduced the risk of restenosis in clinical trials with strict inclusion and exclusion criteria. The objective of this study was to determine the three months clinical outcomes of Everolimus Eluting Stents in patients with stable angina pectoris in Pakistani population. METHODS: It was a descriptive cross-sectional study and the data was collected from Catheterization Laboratory Cardiology Department Lady Readings Hospital Peshawar. Our study included all the patients with stable coronary artery disease who had received Everolimus eluting stents from August, 2013, to April, 2014. Total study duration was 09 months. The primary end points were the rate of target vessel revascularization, myocardial infarction at three months. All those patients who received Everolimus coronary stents were recalled after three months from the index procedure and enquired about target vessel revascularization (TVR), myocardial infarction and hospitalization over the last three months. Data analysis was done using SPSS version 16. RESULTS: Our study included 378 patients with stable ischemic heart disease who underwent revascularization with Everolimus eluting stent. These patients were followed up for a period of 3 months for target vessel revascularization(TVR) and myocardial infarction(MI). Mean age was 57.04±9.307, males were (72%). Left Anterior Descending (LAD) and Left circumflex (LCx) were the predominant vessels vascularized. Mean length of Everolimus eluting stent was 21.91± 4.6 while mean diameter of stent was 2.90±0.248. Thirteen (3.4%) patients had TVR and 14 (3.7%) patients had MI during three months follow up after PCI. TVR and MI were prevalent in patients who received longer Everolimus stents as compared to those who received shorter stents at three months, and the difference between the two was statistically significant. CONCLUSION: Short-term results from this study suggest that real-world outcomes among 378 patients are comparable to those reported in other registries and trials, and safety outcomes as measured by rates of TVR, MI were low. The long-term safety of Everolimus-eluting stents needs to be ascertained in large, randomized trials.

Nonfasting Apo-lipoprotein B and Triglyceride levels as a predictor of coronary heart disease in Type II diabetic patients.

BACKGROUND & OBJECTIVES: Lipoprotein-A has been recognized as a risk factor for ischemic heart diseases. Myocardial infarction (MI) is common complication of ischemic heart disease. Diabetes play an incremental role in the development of coronary artery disease (CAD), however still there are conflicting data regarding the relationship of Lipoprotein-B and MI. We therefore wanted to evaluate the relationship of Lipo-B, MI and diabetes mellitus. Our objective was to determine the non-fasting Apo-lipoprotein B and triglycerides level among type II diabetic patients with ischemic heart disease and to compare with type II diabetic without ischemic heart disease. METHODS: This was cross sectional study where two groups of patients were recruited in the study, Group-I included patient with Ischemic Heart Disease and diabetes while Group-II comprised of diabetes without Ischemic Heart Disease. Age, sex and basic demographic matching was done between the two groups. Data were collected using random sample. The comparative approach was used to see the role of diabetes in the elevation of Apo-lipoprotein B level, which is a risk factor for Ischemic heart diseases. RESULTS: Two hundred forty eight patients (Cases: 123 Diabetic with myocardial infarction and (Control: 125 Diabetic without myocardial infarction) were included in the study. Mean Apo-B among diabetic patients with myocardial infarction was high (68.3±24.23 ng/ml) compared to non-cardiac patients (49.97±33.880 ng/ml) with a p <0.000. Marked difference was also observed in triglycerides levels where it was found very high (301.4±55.1 mg/dL) in patients of diabetes with myocardial infarction as compared to subjects without MI (137.7±84.7 mg/dL). There was positive correlation between Apo-lipoprotein and Triglycerides (P value=039). CONCLUSION: Based on the study result it was concluded that Apo-lipoprotein and triglycerides in diabetic patients with myocardial infarction, had higher levels compared to diabetic patients without Myocardial infarction and this could be a consequence of increase in age, insulin resistance and deficiency of insulin in the body. We also found positive correlation between Apo-lipoprotein and Triglycerides.

Impact of stent length and diameter on short term clinical outcomes of drug eluting stents in patients with stable coronary artery disease.

BACKGROUND & OBJECTIVE: The risk of restenosis and other adverse cardiovascular events with bare-metal stents have increased with smaller stent diameters and longer stent lengths. However, the exact impact of stent size on the short-term outcomes of drug-eluting stent (DES) implantations has not been much classified in Pakistani population. This study was designed to evaluate the impact of size (length and diameter) of Drug Eluting Stents on Clinical outcomes in patient with stable coronary artery disease at three months of implantation in Pakistani Population. METHODS: This is a prospective study which was carried out in the Department of Cardiology, Lady Reading Hospital Peshawar from April 2011 and July 2012. All consecutive patients with stable coronary disease undergoing Percutaneous Intervention (PCI) with DES implantation at Cardiology Unit Lady Reading Hospital, were included prospectively. Clinical outcomes (Myocardial infarction [MI], unstable angina[UA], and positive ETT) at three months stratified by 3 tertiles of stent length and diameter each, were measured in patients who underwent PCI with DES for coronary artery lesions. All patients were followed and reassessed after three months from the index procedure. Exercise Tolerance Test(ETT) was performed on every patient and recorded on proforma. Data analysis was done using SPSS software version 16. RESULTS: A total of 376 patients were included prospectively in this study. The mean age was 57±9.313 years. Male patients were 271(72.1%). Mean length of drug eluting stent was 27.313±7.235 mm while mean diameter of stent was 2.90±0.2483mm. There were slightly higher rates of MI, U.A and positive ETT in the longest stent length tertile(>28mm) compared with the shortest stent length tertile (<22mm) at three months, but they were statistically not significant. We also observed that for DES, there was no clear relationship between stent diameter and outcome for any of the clinical outcome variables. CONCLUSION: In our single-center prospective study, stent length and diameter defined in tertiles, had no impact on the short-term clinical outcomes of DES in patients with stable coronary artery disease.

Comparative analysis of type of myocardial infarction in patients with successful or unsuccessful streptokinase thrombolysis following ST elevation myocardial infarction.

OBJECTIVE: To study the effect of thrombolytic therapy in term of success and failure on the type of ST elevation MI, using streptokinase. MATERIAL AND METHODS: This was a comparative study, conducted at Department of Cardiology, Lady Reading Hospital, Peshawar, from October 2006 to October 2007. Patients with first acute myocardial infarction were divided into group A (successful thrombolysis) and group B (unsuccessful thrombolysis) using ECG criteria. RESULTS: Total number of patients were 200. Group A included 136 (68%) patients and group B included 64 (32%) patients. There were total 88 (44%) patients of anterior MI with 47 patients in group A and 41 patients in group B (34.6% vs 64.0%, p < 0.001). There were total 110 (55.0%) patients of inferior MI with 88 patients in group A and 22 patients in group B (64.7% vs 34.4%, p < 0.001). Lateral myocardial infarction was diagnosed in 2 (1%) patients with 1 patient each in group A and group B (0.7% vs 1.6%, p = 0.583). CONCLUSION: Anterior MI was associated with a higher rate of thromblysis failure while inferior MI and lateral wall MI was associated with a higher rate of successful thrombolysis.

Changing trend of presentation of acute coronary syndrome in Peshawar over the last sixteen years.

BACKGROUND: Once considered as disease of the affluent and developed countries, coronary artery disease is emerging as epidemic in the developing world in general and South Asia in particular. OBJECTIVE: To observe the trend of presentation of acute coronary syndrome in the local population over the last 16 years. MATERIAL AND METHODS: Clinical audit from 1995 to 2010 was carried out in which the data was retrieved from the computerised database of the Department of Cardiology, Lady Reading Hospital Peshawar. The period was divided into four quartiles, and the data of each quartile was analyzed for the total number of admissions, the type of ACS, whether ST-elevated MI or non-ST elevated ACS (comprising unstable angina and non-STEMI), age, gender and mortality. RESULTS: The total admissions into the unit in the first quartile (1995-1998) were 23,827, in the second quartile (1999-2002) 29,005, in the third quartile (2003-2006) 33,206 and in the fourth quartile (2007-2010) were 40,110. Total ACS brunt constituted 8340 (35%), 10,384 (35.8%), 12,180 (36.68%) and 14,920 (37.2%) patients respectively. The mean age of patients was 49.70 +/- 6.4 years, 48.21 +/- 7.2 years, 47.38 +/- 7.1 years and 46.81 +/- 6.2 years respectively. Women were 2356 (28.25% of the total ACS burden) in the first quartile, increasing to 3554 (34.225%), 4817 (39.55%) and 6281 (42.1%) in the following quartiles. STEMI constituted 45.88% (3826) of the total ACS presentations in the first quartile, 47.24% (4905) in the second, 49.55% (6035) in the third and 49.87% (7440) in the last quartile. The mortality rate, however, remained constant throughout (8.4% to 8.8%). CONCLUSION: An increasing trend is seen in the burden of CAD in the local population with increasing presentation as STEMI. It is also evident that CAD is occurring at younger ages and more so in the female population.

Pattern of coronary artery disease with no risk factors under age 35 years.

BACKGROUND: Coronary artery disease (CAD) is no more deemed to be an ailment of the 4th or 5th decade; rather an earlier age incidence is not infrequently encountered in our population. However, there are a few data regarding CAD in young adults, and much about its underlying pathology still remains undetermined. The objective of this study was to delineate the coronary arterial disease pattern in adults under the age of 35 years, but having no known coronary risk factors. METHODS: This prospective study was conducted at the Cardiology Departments of all 3 public sector tertiary care hospitals in Peshawar from Jun 2008 to Dec 2009. After having excluded the traditional risk factors for CAD, patients under the age of 35 years with objective evidence of CAD were subjected to percutaneous coronary angiography. RESULTS: Out of a total of 104 patients, 85 (81.73%) patients were men, and 19 (18.27%) were women. The mean age of the whole group was 32.66 +/- 3.237 (22-35) years. Significant CAD (> 50% diameter narrowing of at least one major coronary artery) was found in 87 (83.7%) patients while 17 (16.3%) patients had non-atherosclerotic coronary artery disease, including 12 (11.53%) patients having normal coronary arteries, 1 (1%) patient had anomalous origin of right coronary artery (RCA), 1 (1%) patient had coronary arteritis, 2 (1.92%) patients had coronary artery ectasia, and 1 (1%) patient had a myocardial bridge over left anterior descending artery (LAD). Among the patients with significant CAD, the prevalence rate of one, two and three vessel disease was 54 (51.9%), 22 (21.2%) and 11 (10.6%) respectively. Almost 50% of the lesions occurred in LAD followed by 25% in RCA and 20% in circumflex, while only one patient (1%) had isolated significant CAD of left main coronary artery. Osteal segments were involved in 10%, proximal in 61%, mid in 21% and distal segments in 7% of the lesions. CONCLUSION: In the younger age group, CAD is mostly a disease of men, single vessel CAD predominates with LAD involvement mostly, predominant osteal to proximal segment involvement of vessels, and a much higher incidence of normal coronaries and non-obstructive CAD is met with.